Nutrition

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5.1 Overall goals

5.1.1 Background

Population nutrient intake goals represent the population average intake that is judged to be consistent with the maintenance of health in a population. Health, in this context, is marked by a low prevalence of diet-related diseases in the population.

Seldom is there a single “best value” for such a goal. Instead, consistent with the concept of a safe range of nutrient intakes for individuals, there is often a range of population averages that would be consistent with the maintenance of health. If existing population averages fall outside this range, or trends in intake suggest that the population average will move outside the range, health concerns are likely to arise. Sometimes there is no lower limit; this implies that there is no evidence that the nutrient is required in the diet and hence low intakes should not give rise to concern. It would be of concern if a large proportion of values were outside the defined goals.

5.1.2 Strength of evidence

Ideally the definition of an increased or a decreased risk should be based on a relationship that has been established by multiple randomized controlled trials of interventions on populations that are representative of the target of a recommendation, but this type of evidence is often not available. The recommended dietary/nutrition practice should modify the attributable risk of the undesirable exposure in that population.

The following criteria are used to describe the strength of evidence in this report. They are based on the criteria used by the World Cancer Research Fund (1), but have been modified by the Expert Consultation to include the results of controlled trials where relevant and available. In addition, consistent evidence on community and environmental factors which lead to behaviour changes and thereby modify risks has been taken into account in categorizing risks. This applies particularly to the complex interaction between environmental factors that affect excess weight gain, a risk factor which the Consultation recognized as contributing to many of the problems being considered.

Convincing evidence. Evidence based on epidemiological studies showing consistent associations between exposure and disease, with little or no evidence to the contrary. The available evidence is based on a substantial number of studies including prospective observational studies and where relevant, randomized controlled trials of sufficient size, duration and quality showing consistent effects. The association should be biologically plausible.

Probable evidence. Evidence based on epidemiological studies showing fairly consistent associations between exposure and disease, but where there are perceived shortcomings in the available evidence or some evidence to the contrary, which precludes a more definite judgement. Shortcomings in the evidence may be any of the following: insufficient duration of trials (or studies); insufficient trials (or studies) available; inadequate sample sizes; incomplete follow-up. Laboratory evidence is usually supportive. Again, the association should be biologically plausible.

Possible evidence. Evidence based mainly on findings from case-control and cross-sectional studies. Insufficient randomized controlled trials, observational studies or non-randomized controlled trials are available. Evidence based on non-epidemiological studies, such as clinical and laboratory investigations, is supportive. More trials are required to support the tentative associations, which should also be biologically plausible.

Insufficient evidence. Evidence based on findings of a few studies which are suggestive, but are insufficient to establish an association between exposure and disease. Limited or no evidence is available from randomized controlled trials. More well designed research is required to support the tentative associations.

5.1.3 A summary of population nutrient intake goals

The population nutrient intake goals for consideration by national and regional bodies establishing dietary recommendations for the prevention of diet-related chronic diseases are presented in Table 6. These recommendations are expressed in numerical terms, rather than as increases or decreases in intakes of specific nutrients, because the desirable change will depend upon existing intakes in the particular population, and could be in either direction.

In Table 6, attention is directed towards the energy-supplying macronutrients. This must not be taken to imply a lack of concern for the other nutrients. Rather, it is a recognition of the fact that previous reports issued by FAO and WHO have provided limited guidance on the meaning of a “balanced diet” described in terms of the proportions of the various energy sources, and that there is an apparent consensus on this aspect of diet in relation to effects on the chronic non-deficiency diseases.

This report therefore complements these existing reports on energy and nutrient requirements issued by FAO and WHO (2-4). In translating these goals into dietary guidelines, due consideration should be given to the process for setting up national dietary guidelines (5).

Table 6. Ranges of population nutrient intake goals

Dietary factor

Goal (% of total energy, unless otherwise stated)

Total fat

15 - 30%

Saturated fatty acids

<10%

Polyunsaturated fatty acids (PUFAs)

6 - 10%

n-6 Polyunsaturated fatty acids (PUFAs)

5 - 8%

n-3 Polyunsaturated fatty acids (PUFAs)

1 - 2%

Trans fatty acids

<1%

Monounsaturated fatty acids (MUFAs)

By differencea

Total carbohydrate

55 - 75%b

Free sugarsc

<10%

Protein

10 - 15%d

Cholesterol

<300 mg per day

Sodium chloride (sodium)e

<5 g per day (<2 g per day)

Fruits and vegetables

≥400 g per day

Total dietary fibre

From foodsf

Non-starch polysaccharides (NSP)

From foodsf

a This is calculated as: total fat - (saturated fatty acids + polyunsaturated fatty acids + trans fatty
acids).b The percentage of total energy available after taking into account that consumed as protein and fat, hence the wide range.c The term "free sugars" refers to all
monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, syrups and fruit juices.d The suggested range should be seen in the light of the Joint WHO/FAO/UNU Expert Consultation on Protein and Amino Acid
Requirements in Human Nutrition, held in Geneva from 9 to 16 April 2002(2).e Salt should be iodized appropriately (6). The need to adjust salt iodization, depending on observed sodium intake and
surveillance of iodine status of the population, should be recognized.f See page 58, under "Non-starch
polysaccharides".